Month / February 2008

Yes, I admit it. I did it. I realized that I’m both altruistic and stupid enough to volunteer to be a relief charge nurse. As I previously stated so poetically, “Ain’t ever going to happen.” But it did. I sat and thought about it. In fact I agonized over it. I talked it over ad nauseum with my wife. In the end I made my manager work for it. It almost became a game to see how long I could hold out. She kept coming back though. Asking me why I didn’t want to do it. Telling me that many of my co-workers had said I would be great. In the end I capitulated. I told her that I would do it. Besides, it was time for my review and I figured telling her “yes”might cast a favorable light on said review.
There are a couple of reasons why I decided to do so. First, I thought that instead of bitching about all the problems on the unit I could take ownership of it and try to change it from the inside (hence, altruistic). Second, I talked to several other charge nurses who allayed my fears and gave me a little insight into the job. One spoke of the “change of pace” that being charge amounted to. Third, I tried it out on several of my friends at work, who unanimously agreed that I would make a great leader as a charge nurse. They blew smoke up my ass, figuratively, and sad that compared to certain charge nurses who do jack shit, I would be a welcome change. Finally, I thought, “hmmm, it would look good on a resume.”

I spent 3 days training to be in charge. Like everything I’ve done lately, I pushed to do it all. I figure, there’s not going to be anyone backing me up when it’s only me, so I better get used to it. I lucked out. The three days were not exceptionally bad. It had its comical moments, like every time I tried to give a certain nurse a new patient, they would get sent to the Unit. Three times this happened. If I could only be so lucky next time. What amazed me is the mess of bureaucratic crap that one has to deal with. Paperwork galore. Being the rational, deep-thinking person I am (trying not to smirk here…) I can see why it was all important, but what a mind-numbing process!

Overall, it went well. No one hates me (that they’ve told me), yet. They continually ask when “the next time is.” So we’ll see. I’m on my own in 2 weeks. Two days as charge. I can see how it a change of pace. It is completely different from bedside nursing. You see, being a 46 bed unit (the biggest in the hospital) we’re busy, even at night. Charge does not take patients. If anything they are a resource nurse for all the other nurses. The night is spent doing administrative work, assigning beds and helping out where needed. It is very different. And I kind of like it.

Yes, I was sad when I heard they were going to tear it down. I spent many, many, many evenings & nights ensconced in a both at this very Denny’s. I even wanted to flim a movie there, a take-off on “Weekend at Bernie’s” called, “Weekend at Denny’s.” After leaving to go to school, whenever I came back to town, inevitably I would end up here. I even took my wife there to see where I hung out in high school.

It was a part of my neighborhood, just down the street from my high school and a cultural touchstone (cheesy? yes.) of that neighborhood. But landmark? You be the judge. Guess it’s better than a slew of new condos, the last thing that particular area needs.

About a week ago a resource nurse who comes to our floor a lot and I were talking and commiserating on the fact she had a trio of poopers. “All I’m doing tonight is cleaning up poop. Even though one has a flexi-seal, it’s still leaking out.” she said.

“Well at least you were prepared for it…your undershirt is kind of c-diffy colored…” I came back with.

“Yeah thanks, I know Captain Obvious.” she said, “It wasn’t the best choice. I should’ve known with this floor!”

And then I said it. The phrase that would doom me into poop-servitude: “Y’know, I haven’t had a night like that in a long time.” Stupid. Stupid. Stupid. It’s like saying “q—–” on a full-moon night, or “she’s finally asleep” about the demented old lady who had been trying to climb out of bed all night. In the grand karmic wheel of nursing, I just steeped in it.

So I show up Tuesday night, flushed with excitement from a nice ride into work, changed and ready to rock. And I start looking at my assignment.

#1: “bradycardia, s/p CV“. OK, he’s a walkie-talkie, fine.

#2: “synope” Again, OK, she looks like a walkie-talkie.

#3: “s/p CABG with AVR, post-op delirium and colitis.” Uh-oh…look a little further down the sheet on him, “mulitple loose stools, (c-diff – !)”
“Yep, could be fun but at least he doesn’t have c-dif,” I thought. Then I read a bit further, “Neuro: A & O x1-2, weak, 2+ assist up, left-sided weakness (new?), strict bedrest.” Now things were getting interesting.

#4: “sepsis, due to C-DIFF.” Yes, here it was the karmic retribution for the words so casually spoken the week before. “Neuro: confused and forgetful, A & O x1-2; Activity: up with 2+ max assist. GI/GU: foley, incont. of stool, 1 loose/mucoid stool.” That’s all of the report I needed. It was going to be one of those nights. Karmic payback.

The day nurse then told me, “Yeah, I d/c’d the flexi-seal yesterday.” I nod glumly, knowing that I would be spending quite a bit of time in the room that night.

So as the night evolved, I did the nursing thing. Checking briefs everytime I head into the room. 2100: still ok. 23:00: so far so good. 24:00, “awwww, hell naw”. Blow-out in #4….I felt like paging overhead, “clean-up on aisle three, clean-up on aisle three.” and clean-up we did. Nothing like a full-bed change blow-out session.

Then #3 rings, “yeah, I ate an apple, then I shit,” he says. That’s one of the things I love about old men, they’re so…well…honest. Clean him up. I’m out of the room less than 10 minutes, “Yeah,” as I answered the call-light,”I shit again.” And on, and on, and on. Cleaned him up 5 more times that night. The C-Diff lady? Nary a time after the blowout.

Fast forward to night #2. I still think I have poop on me somewhere. Even though I have new scrubs on and showered twice since being here. I can still sense it. Not really smell it, bu it more like sensing it, just out of conscious smell range, but there, like the lingering after scent of a bad bar night.

Same peeps. New issue though. Find out #3 has VRE. In his stool. That we had been cleaning for days on end. Without gowns. OK, so make that 2 peeps on contact precautions. And still pooping. Lots.

About midnight I call up Materials, “Hey, this is Wanderer up on 4. Can you send up some more of the big blue chux and another 4 or so packs of isolation gowns and a box of the peri-wipes? We’re going through them like they’re going out of style.”

And the battle continued. I think I singed off all of my olfactory nerve endings those 2 nights because I couldn’t smell anything when I go home in the morning. After I left each room, the smell no longer lingered, it’s like there was nothing for it to linger on. They were gone. Which I guess could be a good thing.

Onto Night 3.

Charge nurse (different on from the past 2 nights) hands me my assignment and says, “I took away #3 from you, it’s just not fair to have 2 isolation patients.”

“Uh. OK, I had them both last night…but I’m not going to complain.” I said. But in fact, it was worse. Instead of having 2 poopers, that I know well, and have kind of gotten used to their unique idiosyncrasies (i.e. smell), I get one and a new cast of characters.

In retrospect, it was OK. She was just spreading the love. Out of the 6 nurses on my particular side of the floor, everyone had at least 1 isolation patient, most were contact, for c-diff. So we all had the love that night.

Part of me says she’s totally wrong, the other part says, “Right On!” I guess it depends on if I’ve jut worked 3 days straight up to my elbows in poop, or am infected with the latest election year bug. I just don’t know. Food for thought though.

I know that it sounds like the classic FDGB (Fall Down Go Boom!) syndrome, bu in my eyes, it’s something different. I’m talking about DNR status. Lately some of docs, most notably residents, have been writing rather bizarre and oft-times confusing DNR orders. Our DNR sheet has four sections. First, is “Full Code,” simple, classic and easy. Second, is “Do Not Resuscitate, no interventions, comfort care only, let them pass in peace. Third is “DNR with Limited Interventions” meaning no extreme measures, no transfers, but not just leave them be. Finally there is my favorite, “DNR with Advanced Interventions.” A fine catch-all that allows the docs and patients to fine-tune exactly how much we can do. And does it every get creative from there. Here’s a fine selection:

You had better choose your drugs quick ’cause you only have 2 minutes to get them into circulation. Hmmm…what’s that? ACLS guidelines? Right, we don’t even give drugs until at least a round of CPR has been done . So we burned up our CPR and really who is paying attention to time in a code? We’d going hell-bent for leather and someone will pop up and say, “Oh, minutes are up.” It wold be like when you’re walking someon with nasal cannula on and they run out of tether, you get that jerk back, where their head snaps back and they’re pulled up short like a fish on a hook.

“No defibrillation, no intubation, no CPR, vasopressors and antiarrythmatics OK.”

Hence why I call it a gravity code. Push the drugs in, give it a good 20ml saline flush and hold that extremity up in the air and let gravity get the drugs into circulation. Seems like it would work fine. Maybe do a little massage to puch it down the vein back towards the heart while you’re at it. Kind of like external counter-pulsation…technically it’s not CPR. I mean who cares that we have to overcome capillary pressure, much less bridge the gap from that antecubital IV site to the heart and then into circulation.

“CPR OK, no drugs no defibrillation, no intubation.”

Right, so we have nothing to shock the heart back to an organized rhythm. Studies (which I’m not going to go Google now) have shown that electricity is the best treatment after good CPR in event of a cardiac arrest. The American Heart Association considers this top-tier evidence based practice, and adjusted the algorithms for VT and VF to include a shock quickly after start of he event. Sure, we can perfuse the body with CPR, but if the heart is acting all crazy and not maintaining an adequate perfusing rhythm, all that CPR will do for naught when you stop. Maybe in cases like this we should all line up and yell, “BOO!” at the heart in order to shock it back to rhythm. I can hear it now:

Team Leader: OK, let’s have a rhythm check. Still Vfib? OK, I want a verbal shock…who’s turn is it?”

It would be like the scene in Airplane where we’re all be lined up yelling at the chest, “Get ahold of youself…”

Again, doesn’t seem all that effective.

Finally, my favorite. Wait for it…

“Ask patient.”

Yes. You read that right. Ask. The. Patient. In the middle of a code. When technically they’re dead. I’m sure that’s going to work very well.

“Umm…excuse me sir. Even though you’re unresponsive, have no pulse and are not breathing, per your DNR orders do you want us to code you?”

Let’s just say the resident and the attending had a long discussion about the appropriateness of their orders.

I know that it stems from the worry that by being a DNR it means we won’t treat the problem. DNR does not mean Do Not Treat. Infact, we will do what we can to avoid a code situation. It also stems from the belief in American society that death is not a natural extension of life, but something to be avoided. And by declaring you’re a full code it means that you (or your family that it wracked by feelings of guilt for their mistreatment of you) are not going to give in the Reaper. Even it that means spending your last days intubated, on multiple pressors, being fed through a tube, in pain from cracked ribs earned in the massive code, in renal failure on CVVH and never regaining consciousness to talk and explain your wishes to your family. It’s the lack of understanding that death is as much of a a part of life as birth is. But with the prevailing dream of living forever coupled to classic American arrogance has led to a multitude of ridiculous and untenable wishes. We don’t want to die because we cannot accept that we can’t be fixed. We don’t want to leave our families. But in this denial of death, we leave our families in a lurch, left adrift and controlled by their own emotions on how to proceed. Unless you put your wishes in writing, we will do everything we can.

I leave with a contrast.

Case A, younger, but with end-stage CHF due to a life of hard living. Coded for 40+ minutes, multiple attempts at intubation, central line placed, labs, 2 shocks, 30+ minutes of CPR, 3/4 of all the drugs in the code cart and never maintained a pulse and never woke up. Traumatic, intense and in the end still despite our best efforts died.

Case B, end-stage COPD, DNR on supportive and comfort measures, i.e. morphine, oxygen, eating what they wanted, found on early rounds dead. They had passed peacefully in the night, quietly, without trauma, calmly but the end result was the same. We knew whe was going, it was just a matter of time. Family had accepted it, they accepted it and we as staff accepted it.